Crisis Resolution and Home Treatment Teams [61]

Who is the Service for?

Commonly adults (16 to 65 years old) with severe mental illness; (e.g. schizophrenia, manic depressive disorders, severe depressive disorder) with an acute psychiatric crisis of such severity that, without the involvement of a crisis resolution/home treatment team, hospitalization would be necessary.

(NB) In every locality there should be flexibility to decide to treat those who fall outside this age group where appropriate.

This service is not usually appropriate for individuals with:

• Mild anxiety disorders
• Primary diagnosis of alcohol or other substance misuse
• Brain damage or other organic disorders including dementia
• Learning disabilities
• Exclusive diagnosis of personality disorder
• Recent history of self harm but not suffering from a psychotic illness or severe depressive illness
• Crisis related solely to relationship issues

What is the Service Intended to Achieve?

People experiencing severe mental health difficulties should be treated in the least restrictive environment with the minimum of disruption to their lives. Crisis resolution/home treatment can be provided in a range of settings and offers an alternative to inpatient care. The majority of service users and carers prefer community-based treatment, and research in the UK and elsewhere has shown that clinical and social outcomes achieved by community-based treatment are at least as good as those achieved in hospital. A crisis resolution/home treatment service should be able to:

• Act as a 'gatekeeper' to mental health services, rapidly assessing individuals with acute mental health problems and referring them to the most appropriate service
• For individuals with acute, severe mental health problems for whom home treatment would be appropriate, provide immediate multi-disciplinary, community based treatment 24 hours a day, 7 days a week
• Ensure that individuals experiencing acute, severe mental health difficulties are treated in the least restrictive environment as close to home as clinically possible
• Remain involved with the client until the crisis has resolved and the service user is linked into on-going care
• If hospitalisation is necessary, be actively involved in discharge planning and provide intensive care at home to enable early discharge
• Reduce service users' vulnerability to crisis and maximise their resilience

Experience indicates that the following principles of care are important:

• A 24 hour, 7 day a week service
• Rapid response following referral
• Intensive intervention and support in the early stages of the crisis
• Active involvement of the service user, family and carers
• Assertive approach to engagement
• Time-limited intervention that has sufficient flexibility to respond to differing service user needs
• Learning from the crisis

Hours of Operation

• The service should be available 24 hours a day, 7 days a week.
• A shift system reflecting differing working patterns is required. A minimum of two trained case workers should be available at all times.
• Evening/through the night working is usually an on-call system.
• Medical on call rota should allow senior psychiatrist to undertake home visits 24 hours a day.
• Assessment team for acute assessment of new referral (available 24 hours a day): two trained case workers and a senior psychiatrist.
• Home visits to known service users (available 24 hours a day): two case workers.

Referrals

Referral to the service should be easy and pathways of care clear to all involved. The service should have a system in place that allows direct referrals from primary care, community mental health teams, ASWs, staff on inpatient wards, the criminal justice system, non-statutory agencies, former service users and their family/carers, A+E departments and other parts of the acute medical service.

Risk Assessment and Policy On Violence

• Each team should have a written policy outlining the level of risk the team is able to manage.
• Operational policy should explicitly address staff safety.

Staff Training Should Include:

• Principles of the service, cultural, gender and anti-racist training
• Skills in delivering all of the interventions listed above
• Team building, colleague support and working within a team framework
• Medication - storage, administration, legal issues, concordance training, side effect awareness
• Use of Mental Health Act and alternatives to hospital treatment
• Benefits to service user and family/carers of home treatment approach

Service User Information

Service users and their family/carers should be provided with the following information:

• Description of the service, range of interventions provided and what to expect
• Name and contact details of care coordinator and other relevant members of the team
• Contact details for out of hours advice and help
• Care plan and comprehensive information about medication
• Relapse prevention and crisis plan
• Discharge plan
• How to express views on the service.

Continual Service Improvement

Regular audit of the service should be undertaken to ensure that gaps in service provision are filled. Audit should always include feedback from service users and their family/carers.